Why Employees Skip Medical Care and How Employers Can Fix It Through Better Benefit Plan Design
Most employers offer health benefits to support healthy, productive employees. But having coverage doesn’t guarantee people get the care they need.
Research shows many insured employees still delay or skip necessary care, which can harm both their health and employers’ bottom lines.
Insured employees skip care for three main reasons: high out-of-pocket costs, access barriers, and confusion about benefits. Here’s how smarter plan design fixes all three.
Insurance Coverage Does Not Guarantee Access to Care
Employers often assume that offering health insurance equals access to healthcare. But data tells a different story. This gap between coverage and utilization reveals a key issue in today’s healthcare system:
Insurance alone does not remove financial, logistical, or psychological barriers to care.
For employers focused on managing healthcare costs and improving the health of their workforce, this distinction matters.
Why Do Employees Delay or Skip Medical Care Even When They Have Insurance?
There are three primary reasons insured employees delay or avoid healthcare:
1. High out-of-pocket costs
2. Access barriers
3. Perception and navigation challenges
Each of these factors directly impacts healthcare utilization and long-term costs.
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High Out-of-Pocket Costs Remain a Major BarrierEven with employer-sponsored insurance, many employees face deductibles, copays, and coinsurance that feel unpredictable or unaffordable. Research shows:
This highlights a critical issue in health plan design: coverage does not always equal affordability. Employees may ask:
When costs feel uncertain, many people choose to delay care and the consequences are significant. What begins as a manageable condition can escalate into an emergency department visit or hospital admission, dramatically increasing healthcare spend for both the employee and the employer. |
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Access BarriersCost is not the only reason employees skip care. Access issues also play a substantial role. Large surveys show that 42% of employees delayed care because they couldn’t get an appointment when they needed one. Common barriers to access include:
Access isn’t just about proximity; it’s about convenience, and available capacity. When employees face weeks-long waits to see a physician, they’re more likely to delay care until symptoms become urgent. For employers, these delays often result in higher claims costs later. |
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Perception, Confusion, and Poor Care NavigationAnother major reason employees skip care is perception. Some individuals believe preventive services or screenings are unnecessary, particularly if they feel healthy. Others may not understand what their benefits cover or how to access care effectively. Poor digital experiences also create friction:
When the healthcare system feels overwhelming or confusing, avoidance becomes easier than engagement. This behavioral component is often overlooked in employer health benefit plan design discussions. |
How Does Employees Delaying Care Increase Employer Healthcare Costs?
When employees skip care, the effects don’t stay isolated in their personal lives. Employers feel the impact through:
1. Increased long-term health effects
Untreated conditions tend to worsen. Delaying preventive care or chronic disease management often results in more complex conditions that are more difficult to treat.
2. Lost productivity
Workforce productivity declines when employees are not physically or mentally well. Unaddressed health issues lead to absenteeism, presenteeism (working while sick), and extended time away from work.
3. Higher overall plan spend
Skipping care does not reduce spending; it shifts spending into more expensive categories. Delayed care can lead to emergency visits and hospital admissions, which are significantly more expensive than early intervention.
How Can Employers Reduce Delayed Care Through Health Benefit Plan Design?
If the problem is cost, access, and confusion, the solution lies in smarter employer health benefit plan design. Strategic plan design can actively encourage appropriate care utilization while controlling overall healthcare costs.
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Use Steering and Tiering to Lower Financial BarriersSteering incentives and tiered provider networks are powerful tools for improving healthcare utilization. In a tiered benefit plan:
Steering incentives, like cash incentives for choosing specific providers for shoppable procedures, further reinforces healthcare consumerism by guiding employees toward providers that deliver lower-cost care. |
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Improve Care Navigation and Decision SupportHigh-performing employer health benefit plan designs include care navigation tools and support that help people find the right care, at the right time, and in the right setting. These resources reduce confusion, point employees toward preventive care, and help them get needed services before conditions escalate. Care navigation tools include:
When employees understand where to go, what it will cost, and why it matters, they are more likely to follow through with care. |
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Strengthen Network Strategy to Improve AccessNetwork design plays a crucial role in healthcare utilization. Employers can partner with providers who offer:
When employees are able to receive services when they need them at lower costs, they are more likely to act early rather than delay care. |
The Bottom Line: Design Benefit Plans for Utilization
Smart employer health benefit plan design, including steering and tiering, care navigation, and high-performance networks, bridges the gap between coverage and access.
When high-value healthcare options are affordable, easy to schedule, and simple to understand, utilization improves. And when care utilization improves, outcomes improve, and unnecessary spending declines.
For employers focused on bending the medical cost trend while supporting employee health, benefit plan design is a strategic lever.
The Alliance works with employers to design plans that change incentives and reduce barriers. By making high-value healthcare easier and more affordable, employers can improve outcomes, strengthen workforce health, and manage costs more effectively.
Whether you’re new to self-funding or are looking to strengthen your current benefit strategy, connect with us to learn how you can design a benefit plan that drives better outcomes for your employees and better value for your business.
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Kristin Andro
Account Executive
Kristin Andro joined The Alliance in 2024 as an Account Executive. She has over 15 years of experience, including roles at UnitedHealthcare, Employer Account Executive at Prime Therapeutics, and Large Group Sales Account Executive at Quartz Health Solutions.
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